Peter Bach and Robert Kocher make an argument in The New York Times that I hear frequently from physicians but continue not to really understand. Their claim is that the high cost of medical school accounts for why so few doctors want to be GPs:
Huge medical school debts — doctors now graduate owing more than $155,000 on average, and 86 percent have some debt — are why so many doctors shun primary care in favor of highly paid specialties, where there are incentives to give expensive treatments and order expensive tests, an important driver of rising health care costs.
But how does this work. Imagine a person with two career choices. One is highly paid specialist, the other is middling paid primary caregiver. One doesn’t need any exotic assumptions about debt to understand why the person might be inclined to choose highly paid specialist. It’s the high pay! Now if you assume that the specialist isn’t actually earning a higher wage, but is simply making a different tradeoff between hours worked and leisure time then it makes sense. The more debt you have, the more likely you are to forego leisure in favor of more work. But my understanding is that this isn’t the issue, the specialists actually earn more.
The proposal Bach and Kocher outline looks fiscally sound (the money involved in making medical school free is earned back through higher fees through certain kinds of training) so I’m all for giving it a shot. But the fundamental issue is simply that we shouldn’t be overpaying for ineffective specialist treatments. You tackle that, I think, by tackling it directly — aggressive payments reforms in Medicare, in the new health insurance exchanges, and if necessary in any plan benefitting from government tax subsidies. The maine role I see for medical education is that in exchange for making medical school cheaper we should also make it more plentiful and be training a higher quantity of doctors.